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Although it has been shown that patient socioeconomic status (SES) is associated with the surgical treatments chosen for severe peripheral arterial disease (PAD), the association between SES and outcomes of arterial reconstruction have not been well-studied. The objective of this study was to determine if SES is associated with outcomes following lower extremity arterial reconstruction.Patients 40 years and older who had surgical revascularization for severe lower extremity PAD were identified in the Nationwide Readmissions Database, 2010 to 2014. Measures of SES including median household income (MHI) quartiles of patients' residential ZIP codes were extracted. Factors associated with repeat revascularization, subsequent major amputations, hospital mortality, and 30-day all-cause readmission were evaluated using multivariable regression analyses.Of the 131,529 patients identified, the majority (61%) were male, and the average age was 69 years. On unadjusted analyses, subsequent amputations were higher among patients in the lowest MHI quartile compared with patients in the highest MHI quartile (13% vs 10%; overall P .001). On multivariable analyses, compared with patients in the lowest quartile, those in the highest quartile had lower amputation (adjusted odds ratio [aOR], 0.70; 95% confidence interval (CI), 0.63-0.77; overall P .001) and readmission (aOR, 0.91; 95% CI, 0.84-0.99; overall P = .028) rates. However, subsequent revascularization (aOR, 1.04; 95% CI, 0.94-1.15) and mortality (aOR, 1.01; 95% CI, 0.79-1.28) rates were not different across the groups.Lower SES is associated with disproportionally worse outcomes following lower extremity arterial reconstruction for severe PAD. These data suggest that improving outcomes of lower extremity arterial reconstruction may involve addressing socioeconomic disparities.

Major socioeconomic disparities persist in the management and outcomes of peripheral artery disease (PAD) globally. Allostatic load, which is described as a measure of physiologic adaptation to socio-environmental stress, has been reported to partially explain higher mortality rates in US Blacks. However, it is not clear if allostatic load is associated with PAD severity. The National Health and Nutrition Examination Survey (NHANES), 2003-2004 data was used to identify individuals with PAD based on the calculated Ankle-Brachial Index (ABI). After allostatic load was calculated for each individual, the cohort was stratified into tertiles of allostatic load and survey weights were used to generate nationally representative estimates. Factors associated with increased severity of PAD were evaluated using multivariate regression analyses. There were 5589 individuals included in the survey and 239 (5.9%) had PAD (ABI ≤ 0.9). Using survey weights, this corresponded to 5.9 million individuals. Individuals with PAD were more likely in the highest tertile of allostatic load (71%) compared to the middle (28%) or lowest (6%) tertiles. However, when severity of PAD was examined, the odds of moderate-to-severe PAD were not significantly different among individuals in the middle [adjusted Odds Ratio: 2.02 (0.52 - 7.80)] or highest [adjusted Odds Ratio: 2.53 (0.69 - 9.26)] tertiles compared to those in the lowest tertile. This study suggests that PAD severity is not associated with allostatic load. Increased efforts are necessary to identify factors that explain the socioeconomic disparities observed in the management and treatment of PAD. Key words: Allostatic load, outcomes, peripheral arterial disease, severity, socioeconomic.

Objective To examine patterns and trends of firearm injuries in a nationally representative sample of US women. Summary background data Gun violence in the United States exceeds rates seen in most other industrialized countries. Due to the paucity of data little is known regarding demographics and temporal variations in firearm injuries among women. Methods Data was extracted from the Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System (2001 - 2017) for women 18 years and older. Number of non-fatal firearm assaults and homicide per year were extracted and crude population-based injury rates were calculated. Sub-stratification by age-group and time period were performed. Results Between 2001 and 2017, there were 88,823 non-fatal firearm assaults involving women and 29,106 firearm homicides. There were 4,116 victims of non-fatal firearm assault in 2001 (3.8 per 10) and 12,959 by 2017 (10.0 per 10). Homicide rates were 1.5 per 10 in 2001 and 1.7 per 10 in 2017. Sub-stratification by age-group and time period showed that there were no significant changes in non-fatal firearm assault rates between 2001 and 2010 (P-trend = 0.132 in 18 - 44 yo; 0.298 in 45 - 64 yo). However between 2011 and 2017, non-fatal assault rates increased from 7.10 per 10 to 19.24 per 10 in 18 - 44 yo (P-trend = 0.013) and from 1.48 per 10 to 3.93 per 10 in 45 - 64 yo (P-trend = 0.003). Similar trends were seen with firearm homicide among 18 - 44 yo (1.91 per 10 to 2.47 per 10 in 2011-2017, P-trend = 0.022). However, the trends among 45 - 64 yo were not significant in both time periods. Conclusions Female victims of gun violence are increasing and more recent years have been marked with higher rates of firearm injuries, particularly among younger women. These data suggest that improved public health strategies and policies may be beneficial in reducing gun violence against US women.

Although the numbers of older adults in the US are rapidly increasing, there is sparse recent data on the use and outcomes of coronary artery bypass grafting (CABG) among this population. We aimed to evaluate the characteristics and outcomes of older adults undergoing CABG and to measure temporal trends.Using data from the National Inpatient Sample (2005-2014), patients aged 85 y and older who underwent CABG were selected. Demographic, clinical, and hospital characteristics were extracted. Outcomes measured were hospital mortality, hospital length of stay, discharge home, and operative complications. Patients were grouped by 2-year increments. Differences in clinical characteristics and outcomes over time were evaluated using trend analyses.There were 60,124 patients included in the cohort. The mean age was 86.8 y with majority being men (61%), white (88%), and treated in teaching hospitals (61%). Over the study period, the annual surgical volume decreased from 6689 in 2005/06 to 5150 in 2013/14. Mortality decreased from 8.5% to 5.5% (P-trend0.001) and mean hospital length of stay decreased from 13.9 d to 12.0 d (P-trend0.001), whereas the rate of discharge home remained stable (14.1% versus 11.6%, P-trend = 0.056). Compared with patients in 2005/06, those in 2013/14 had higher comorbidities [diabetes: 27.6% versus 17.3%; chronic kidney disease: 29.8% versus 9.2%; peripheral artery disease: 7.5% versus 6.0%; and hypertension: 83.7% versus 64.5% (all P-trend0.001)].CABG volumes are decreasing among older adults, and comorbidity burden is increasing, but outcomes are improving. These data may indicate improved preoperative optimization and better perioperative care processes.

Background Over 350,000 surgeries are performed for ventral hernias (VHs) annually. Abdominal wall component separation has been more frequently used for the management of VHs. The goal of this study is to better understand factors associated with component separation complication rates. Methods The National Inpatient Sample (2005-2014) was used to identify all patients with an International Classification of Diseases ninth Revision diagnosis of VHs who underwent open VH repair with a pedicleor graft advancement flap. All cases included in this study were elective and not associated with additional procedures. Demographic, clinical, and hospital characteristics were extracted. Independent predictors of complications and outcomes were determined by multivariable regression analysis. Results Component separation was performed in 4346 patients. Mean age was 56; majority were female (55%) and white (80%). Most patients (73%) underwent surgery in an urban teaching hospital; mesh was used in 80% of cases and 11% were smokers. Hypertension was the most common comorbidity (50%), followed by obesity (26%), diabetes mellitus (DM) (23%), coronary artery disease (11%), and chronic obstructive pulmonary disease (COPD) (8%). Half of the patients (50%) had private insurance, and 35% had Medicare. Patients were distributed equally over household income quartiles. The mortality rate was 0.5%; median length of stay was 5 d. Overall complication rate was 25% (wound 11%, intraoperative 5%, infectious 11%, and pulmonary 8%). Mesh was associated with a lower rate of wound complications (10% versus 15%, P = 0.001). On multivariable analysis, patients with COPD (odds ratio: 2.02; 95% confidence interval: 1.58-2.59), obesity (1.37; 1.16-1.63), DM (1.3; 1.09-1.55), and those in the lowest income quartile (1.44; 1.06-1.96) had higher overall complication rates. Conclusions Consistent with other studies, patients with COPD, Obesity, DM, and lower income status were associated with increased complications after component separation.

Background Older data indicate that less patients undergo surgery for complicated peptic ulcer disease (PUD). We evaluated contemporary trends in the surgical management and outcomes of patients with complicated PUD. Methods The National Inpatient Sample (2005-2014) was queried for patients with complicated PUD (hemorrhage, perforation, or obstruction). Trend analyses were used to evaluate changes in management and outcomes. Results There were 1 570 696 admissions for complicated PUD during the study period. Majority (87.0%) presented with hemorrhage, 10.6% presented with perforation, and 2.4% had an obstruction. The average age was 67 years. Overall, admissions with complicated PUD decreased from 180 054 in 2005 to 150 335 in 2014. The proportion of patients managed operatively decreased from 2.5% to 1.9% in the hemorrhage group, 75.0% to 67.4% in the perforation group, and 26.0% to 20.2% in the obstruction group (all P-trend < .05). Overall, among patients managed operatively, the use of acid-reducing procedures decreased from 25.9% to 13.9%, mortality decreased from 11.9% to 9.4% (both P-trend < .001), while complications remained stable (10.4% to 10.3%, P-trend = .830). Conclusions There are fewer admissions with complicated PUD and more patients are treated nonoperatively. Despite subtle improvements, significant proportions of patients still die from complicated PUD indicating the need for improved preoperative optimization and postoperative care among these patients.

Cholecystectomy is the most commonly performed procedure in sickle cell disease (SCD) patients, but outcomes after cholecystectomy have not been well studied. Our aim was to explore the characteristics and outcomes of cholecystectomy in patients with SCD compared with patients without SCD, and assess whether acuity of presentation played a role.Patients younger than age 35, with the primary diagnosis of gallbladder disease, who underwent cholecystectomy, were identified in the Nationwide Inpatient Sample (2005 to 2014). Patients were grouped into treatment groups by sickle cell status and acuity of surgery. Patient demographics, length of stay, hospital charges, and complications were evaluated. Descriptive and multivariate regression analyses were performed to compare these groups.There were 149,415 patients analyzed; 1,225 (0.82%) had SCD. SCD was associated with higher complication rates (2.69% vs 1.12%), longer lengths of stay (3 days vs 2 days), and higher median hospital charge ($29,170 vs $25,438) (all p0.01). Stratified by level of acuity, comparing the SCD group with the non-SCD group, higher complication rates were seen in the acute presentation group (3.92% vs 1.00%, p0.01), but were not demonstrated in the elective group (0.98% vs 1.95%, p = 0.114).SCD patients appear to have a longer length of stay, higher hospital spending, and increased complication rates compared with non-SCD patients undergoing cholecystectomy. This difference is pronounced among patients who underwent surgery in the acute setting. The data suggest that planned cholecystectomy may be beneficial in improving postoperative outcomes in SCD patients.

Background With the increasing demand for body contouring procedures in the United States over the past 2 decades, more surgeons with diverse specialty training are performing these procedures. However, little is known regarding the comparative outcomes of these patients. Objectives The purpose of this study was to compare outcomes of body contouring procedures based on the specialty training of the surgeon. Methods Data from the American College of Surgeons National Surgical Quality Improvement Program (2005-2015) were reviewed for all body contouring procedures. Patients were stratified by surgeon training (plastic surgery [PS] vs general surgery [GS]). Descriptive statistics and regression analyses were used to evaluate differences in outcomes. Results A total of 11,658 patients were included; 9502 PS cases and 2156 GS cases. Most were women (90.4%), aged 40 to 59 (52.7%) and white (79.5%). Compared with PS patients, GS patients were more likely to be obese (61.4% vs 40.6%), smokers (13.6% vs 9.8%), and with ASA classification ≥3 (35.3% vs 18.6%) (all P < 0.001). Abdominal contouring procedures were the most common (76%) cases. Multivariate regression revealed that compared with PS cases, those performed by GS practitioners were associated with increased wound and infectious complications (adjusted odds ratio [aOR], 1.81; 95% confidence interval [CI], 1.44-2.27), reoperation (aOR, 1.85; 95% CI, 1.31-2.62), and predicted mean length of stay (1.12 days; 95% CI, 0.64-1.60 days). Conclusions The variable outcomes in body contouring procedures performed by PS compared with GS practitioners may imply procedural-algorithmic differences between the subspecialties, leading to the noted outcome differential. Level of Evidence: 2

Exploratory laparotomy (EL) has been the definitive diagnostic and therapeutic modality for operative abdominal trauma in the US. Recently, many trauma centers have started using diagnostic laparoscopy (DL) in stable trauma patients in an effort to reduce the incidence of non-therapeutic laparotomy (NL). We aim to evaluate the incidence of NL in the trauma population in the US and compare the outcomes between DL and NL. Using ICD-9 codes, the National Trauma Data Bank (2010–2015) was queried for patients undergoing any abdominal surgical intervention. Patients were divided into two groups: diagnostic laparoscopy (DL) and exploratory laparotomy (EL). Hemodynamically unstable patients on arrival and patients with abbreviated injury score (AIS) > 3 were excluded. Patients in EL group without any codes for gastrointestinal, diaphragmatic, hepatic, splenic, vascular, or urological procedures were considered to have undergone NL. After excluding patients who were converted to open from the DL group, multivariate regression models were used to analyze the outcomes of DL vs NL group with respect to mortality, length of stay, and complications. A total of 3197 patients underwent NL vs 1323 patients who underwent DL. Compared to DL group, the NL group were older (mean age: 35 vs. 31, P

Obesity is a modifiable risk factor that causes mechanical forces to be exerted within the joints, further contributing to the debilitating effects of osteoarthritis. Total Knee Arthroplasty (TKA) can have a profound impact on patients with osteoarthritis, providing them with increased quality of life, improved function, reduction of pain, while simultaneously preventing the development of additional comorbidities. Although there is inconclusive evidence that increased body mass index (BMI) is linked to increased perioperative complications among TKA patients, recent studies suggest this association exists. The aim of this study is to provide conclusive data on the effects of BMI on perioperative complications in TKA using the national risk-adjusted database, ACS-NSQIP. Our study demonstrated that there was a correlation between increased BMI and perioperative outcomes, particularly with surgical site infections, renal, and respiratory complications. (Journal of Surgical Orthopaedic Advances 29(4):205-208, 2020).

Introduction Trauma center care and survival have been improving over the past several years. However, yearly firearm-related deaths have remained near constant at 33 000. One challenge to decreasing gunshot mortality is patients presenting with complex injury patterns from multiple gunshot wounds (GSWs) made possible by high-caliber automated weapons. Our study analyzes outcomes of trauma patients of firearms using the National Trauma Databank (NTDB). Methods We conducted a retrospective review of the NTDB from the years 2003-2015 for patients with penetrating injuries. We separated patients into groups based on stab wounds, single GSW, and multiple GSW. We performed multivariate logistic regression analyses in which we adjusted for demographics and injury severity. Results Overall, 382 376 patients presenting with penetrating injuries were analyzed. Of those 167 671 had stab, 106 538 single GSW, and 57 819 multiple GSW injuries. Crude mortality was 1.97% for stab wounds, 13.26% for single GSW, and 18.84% for multiple GSW. Adjusted odds ratio (OR) compared with 2003 demonstrates a trend toward decreased mortality for stab wounds (OR range of 0.48-0.69, P < .05 for years 2010-2015). A similar trend was demonstrated in single GSW injuries (OR 0.31-0.83, P < .01 for years 2005-2015). Conversely, multiple GSW injuries did not follow this trend (OR 0.91-1.36 with P > 0.05 for each year). Conclusion In contrast to significant improvement in survival in patients with a single GSW injury since 2003, multiple GSW injuries still pose a challenge to trauma care. This warrants further investigation into the efficacy of legislature, and the lack thereof, as well as future preventative measures to this type of injury.

Trauma patients often require initial stabilization followed by transfer for ongoing trauma care. Thus, the administration of VTE prophylaxis is often delayed until admission to the receiving hospital. It is unclear if transfer status is a risk factor for VTE. The National Trauma Database v6.2 was used to identify patients admitted to Level I and II trauma centers. Exclusions included patients on anticoagulation

INTRODUCTION AND OBJECTIVE:Von Hippel Lindau (VHL) is an autosomal dominant hereditary disorder characterized by multiple neoplastic lesions, including pheochromocytomas. This study retrospectively...

Carcinoma ex pleomorphic adenoma, an uncommon neoplasm of the parotid gland, accounts for less than 4% of salivary gland tumors. It arises from a benign pleomorphic adenoma presenting in the sixth to eighth decades of life. We present this as a unique account of a primary parotid gland carcinoma, arising from myoepithelial cells, without a known precursor lesion, in a 28-year-old woman. This presentation seeks to provide familiarity of an unusual presentation of an unexpected rare pathology in a young female patient and the tools utilized for an accurate diagnosis.

Supplemental material, Table S1, for Gunshot Injuries in American Trauma Centers: Analysis of the Lethality of Multiple Gunshot Wounds by Ahmad Zeineddin, Mallory Williams, Harry Nonez, Wasay Nizam, Olubode A. Olufajo, Gezzer Ortega, Adil Haider and Edward E. Cornwell in The American Surgeon

Background: Racial and socioeconomic disparities are well documented in emergency general surgery (EGS) and have been highlighted as a national priority for surgical research. The aim of this study was to identify whether disparities in the EGS setting are more likely to be caused by major adverse events (MAEs) (e.g., venous thromboembolism) or failure to respond appropriately to such events. Methods: A retrospective cohort study was undertaken using administrative data. EGS cases were defined using International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes recommended by the American Association for the Surgery of Trauma. The data source was the National Inpatient Sample 2012-2013, which captured a 20%-stratified sample of discharges from all hospitals participating in the Healthcare Cost and Utilization Project. The outcomes were MAEs, in-hospital mortality, and failure to rescue (FTR). Results: There were 1,345,199 individual patient records available within the National Inpatient Sample. There were 201,574 admissions (15.0%) complicated by an MAE, and 12,006 of these (6.0%) resulted in death. The FTR rate was therefore 6.0%. Uninsured patients had significantly higher odds of MAEs (adjusted odds ratio, 1.16; 95% confidence interval, 1.13-1.19), mortality (1.28, 1.16-1.41), and FTR (1.20, 1.06-1.36) than those with private insurance. Although black patients had significantly higher odds of MAEs (adjusted odds ratio, 1.14; 95% confidence interval, 1.13-1.16), they had lower mortality (0.95, 0.90-0.99) and FTR (0.86, 0.80-0.91) than white patients. Conclusions: Uninsured EGS patients are at increased risk of MAEs but also the failure of health care providers to respond effectively when such events occur. This suggests that MAEs and FTR are both potential targets for mitigating socioeconomic disparities in the setting of EGS.

Background Post colonoscopy blunt splenic injury (PCBSI) is a rarely reported and poorly recognized event. We analyzed cases of PCBSI managed at our hospital and compared them to existing literature. Methods We identified 5 patients admitted with PCBSI through chart review. Results There were 5 cases of PCBSI identified from April 2016–July 2017. Four of the patients were older than 65 years, three had prior surgeries, and all were women. CT scans showed splenic laceration in 4 cases, hemoperitoneum in 4 cases, and left pleural effusion in 2 cases. Three patients were treated with coil embolization, 1 had open splenectomy, and 1 was observed. Conclusions Although blunt splenic injury is an infrequently reported complication of colonoscopy, it can result in high-grade injury requiring transfusion and invasive treatment due to significant hemorrhage. As previously reported, we demonstrate a high rate of PCBSI in women over 55 with a history of prior abdominal surgery. These data suggest that a high index of suspicion for splenic injury post-colonoscopy should be present in this population.

BACKGROUND Frailty is associated with poor surgical outcomes in elderly patients but is difficult to measure in the emergency setting. Sarcopenia, or the loss of lean muscle mass, is a surrogate for frailty and can be measured using cross-sectional imaging. We sought to determine the impact of sarcopenia on 1-year mortality after emergency abdominal surgery in elderly patients. METHODS Sarcopenia was assessed in patients 70 years or older who underwent emergency abdominal surgery at a single hospital from 2006 to 2011. Average bilateral psoas muscle cross-sectional area at L3, normalized for height (Total Psoas Index [TPI]), was calculated using computed tomography. Sarcopenia was defined as TPI in the lowest sex-specific quartile. Primary outcome was mortality at 1 year. Secondary outcomes were in-hospital mortality and mortality at 30, 90, and 180 days. The association of sarcopenia with mortality was assessed using Cox proportional hazards regression and model performance judged using Harrell's C-statistic. RESULTS Two hundred ninety-seven of 390 emergency abdominal surgery patients had preoperative imaging and height. The median age was 79 years, and 1-year mortality was 32%. Sarcopenic and nonsarcopenic patients were comparable in age, sex, race, comorbidities, American Society of Anesthesiologists classification, procedure urgency and type, operative severity, and need for discharge to a nursing facility. Sarcopenic patients had lower body mass index, greater need for intensive care, and longer hospital length of stay (p < 0.05). Sarcopenia was independently associated with increased in-hospital mortality (risk ratio, 2.6; 95% confidence interval [CI], 1.6-3.7) and mortality at 30 days (hazard ratio [HR], 3.7; 95% CI, 1.9-7.4), 90 days (HR, 3.3; 95% CI, 1.8-6.0), 180 days (HR, 2.5; 95% CI, 1.4-4.4), and 1 year (HR, 2.4; 95% CI, 1.4-3.9). CONCLUSION Sarcopenia is associated with increased risk of mortality over 1 year in elderly patients undergoing emergency abdominal surgery. Sarcopenia defined by TPI is a simple and objective measure of frailty that identifies vulnerable patients for improved preoperative counseling, setting realistic goals of care, and consideration of less invasive approaches. LEVEL OF EVIDENCE Prognostic study, level III.

Firearms are a leading cause of injury and death among children in the United States. Most gun violence studies highlight mortality, but few have examined the morbidity in disfiguring injuries suffered by children. Using National Trauma Data Bank 2007-2015, children who suffered gunshot injuries and underwent procedures with lasting physical disfigurement formed the cohort of this study. We identified 28 593 children as victims of firearm injuries. Most were aged 13-18 (84%). There was a preponderance of male gender (86%) and black race/ethnicity (57%). Total mortality was 3774 (13%), and 1500 (5.4%) were identified with one or more disfigurements: 220 amputations, 191 craniectomy, 100 enucleation, 533 ileostomy/colostomy, and 557 tracheostomies. This report highlights the large toll firearm injuries take on American children, specifically in non-concealable disfigurements. These injuries are very impactful to their education and overall socialization and therefore must be a part of the discussion of gun violence in the United States.

Objectives: Following calls from the National Institutes of Health and American College of Surgeons for “urgently needed” research, the objectives of the present study were to (1) ascertain whether differences in 30/90/180-day mortality, major morbidity, and unplanned readmissions exist among adult (18–64 yr) and older adult (≥65 yr) emergency general surgery (EGS) patients; (2) vary by diagnostic category; and (3) are explained by variations in insurance, income, teaching status, hospital EGS volume, and a hospital's proportion of minority patients. Background: Racial/ethnic disparities have been described in in-hospital and 30-day settings. How longer-term outcomes compare—a critical consideration for the lived experience of patients—has, however, only been limitedly considered. Methods: Survival analysis of 2007 to 2011 California State Inpatient Database using Cox proportional hazards models. Results: A total of 737,092 adults and 552,845 older adults were included. In both cohorts, significant differences in 30/90/180-day mortality, major morbidity, and unplanned readmissions were found, pointing to persistently worse outcomes between non-Hispanic Black and White patients [180-d readmission hazard ratio (95% confidence interval):1.04 (1.03–1.06)] and paradoxically better outcomes among Hispanic adults [0.85 (0.84–0.86)] that were not encountered among Hispanic older adults [1.06 (1.04–1.07)]. Stratified results demonstrated robust morbidity and readmission trends between non-Hispanic Black and White patients for the majority of diagnostic categories, whereas variations in insurance/income/teaching status/EGS volume/proportion of minority patients all significantly altered the effect—combined accounting for up to 80% of risk-adjusted differences between racial/ethnic groups. Conclusions: Racial/ethnic disparities exist in longer-term outcomes of EGS patients and are, in part, determined by differences in factors associated with emergency care. Efforts such as these are needed to understand the interplay of influences—both in-hospital and during the equally critical, postacute phase—that underlie disparities’ occurrence among surgical patients.

Background Although residential segregation has been implicated in various negative health outcomes, its association with kidney transplantation has not been examined. Methods Age- and sex-standardized kidney transplantation rates were calculated from the Scientific Registry of Transplant Recipients, 2000–2013. Population characteristics including segregation indices were derived from the 2010 U.S. Census data and the U.S. Renal Data System. Separate multivariable Poisson regression models were constructed to identify factors independently associated with kidney transplantation among Blacks and Whites. Results Median age- and sex-standardized kidney transplantation rates were 114 per 100,000 for Blacks and 38 per 100,000 for Whites. 16.1% of the U.S. population lived in counties with high segregation. There was no difference in the kidney transplantation rates across the levels of segregation among Blacks and Whites. Conclusion Factors other than residential segregation may play roles in kidney transplantation disparities. Continued efforts to identify these factors may be beneficial in reducing transplantation disparities across the U.S. Summary Using the Scientific Registry of Transplant Recipients and U.S. census data, we aimed to determine whether residential segregation was associated with kidney transplantation rates. We found that there was no association between residential segregation and kidney transplantation rates.

Background: Studies suggest that patients admitted on weekends may have worse outcomes as compared with those admitted on weekdays. Lower extremity vascular trauma (LEVT) often requires emergent surgical intervention and might be particularly sensitive to this “weekend effect.” The objective of this study was to determine if a weekend effect exists for LEVT. Methods: The National and Nationwide Inpatient Sample Database (2005–2014) was queried to identify all adult patients who were admitted with an LEVT diagnosis. Patient and hospital characteristics were recorded or calculated and outcomes including in-hospital mortality, amputation, length of stay (LOS), and discharge disposition were assessed. Independent predictors of outcomes were identified using multivariable regression models. Results: There were 9,282 patients admitted with LEVT (2,866 weekend admissions vs. 6,416 weekday admissions). Patients admitted on weekends were likely to be younger than 45 years (68% weekend vs. 55% weekday, P < 0.001), male (81% weekend vs. 75% weekday, P < 0.001), and uninsured (22% weekend vs. 17% weekday, P < 0.001) as compared with patients admitted on weekdays. There were no statistically significant differences in mortality (3.8% weekend vs. 3.3% weekday, P = 0.209), amputation (7.2% weekend vs. 6.6% weekday, P = 0.258), or discharge home (57.4% weekend vs. 56.1% weekday, P = 0.271). There was no clinically significant difference in LOS (median 7 days weekend vs. 7 days weekday), P = 0.009. On multivariable regression analyses, there were no statistically significant outcome differences between the groups. Conclusions: This study did not identify a weekend effect in LEVT patients in the United States. This suggests that factors other than the day of admission may be important in influencing outcomes after LEVT.

Background About 50% of patients with cancer who have undergone surgery suffer from cancer-related pain (CP). The use of opioids for postoperative pain management presents the potential for overdose, especially among these patients. Objective The primary objective of this study was to determine the association between CP and postoperative opioid overdose among inpatients who had undergone major elective procedures. The secondary objective was to assess the relationship between CP and inpatient mortality, total hospital charge, and length of stay in this population. Methods Data of adults 18 years and older from the National Inpatient Sample (NIS) were analyzed. Variables were identified using ICD-9 codes. Propensity-matched regression models were employed in evaluating the association between CP and outcomes of interest. Results Among 4,085,355 selected patients, 0.8% (N = 2,665) had CP, whereas 99.92% (N = 4,082,690) had no diagnosis of CP. We matched patients with CP (N = 2,665) and no CP (N = 13,325) in a 1:5 ratio. We found higher odds of opioid overdose (adjusted odds ratio [aOR] = 4.82, 95% confidence interval [CI] = 2.68–8.67, P < 0.0001) and inpatient mortality (aOR = 1.39, 95% CI = 1.11–1.74, P = 0.0043) in patients with CP vs no CP. Also, patients with CP were more likely to stay longer in the hospital (12.76 days vs 7.88 days) with higher total hospital charges ($140,220 vs $88,316). Conclusions CP is an independent risk factor for opioid overdose, increased length of stay, and increased total hospital charges.

BACKGROUND : Improving survival rates among patients with breast cancer has been associated with an increase in the prevalence of co-morbidities like cancer-related pain. Opioids are an important component in the management of pain among these patients. However, the progression from judicious use to abuse defeats the aim of pain control. Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as the first step in cancer-related pain management. Due to their anti-inflammatory, anti-neoplastic and neuroprotective properties, NSAIDs have been shown to reduce the risk of progression of certain cancers including breast cancers. In this study, we assessed whether an association exists between long-term NSAID use and opioid abuse among breast cancer survivors. We also explored the relationship between long-term NSAID use and inpatient mortality and length of stay (LOS). METHODS Using ICD-9-CM codes, we identified and selected women aged 18 years and older with breast cancer from the National Inpatient Sample. Our primary predictor was a history of long-term NSAID use. Multivariable regression models were employed in assessing the association between long-term NSAID use and opioid abuse, inpatient mortality and LOS . RESULTS Among 170,644 women with breast cancer, 7,838 (4.6%) reported a history of long-term NSAID use. Patients with a history of long-term NSAID use had lower odds of opioid abuse (adjusted odds ratio (aOR) 0.53; 95% CI [0.32-0.88]), lower in-hospital mortality (aOR 0.52; 95% CI [0.45-0.60]) and shorter LOS (7.12 vs. 8.11 days). DISCUSSION Further studies are needed to understand the underlying mechanism of the association between long-term NSAID use and opioid abuse.

Gun violence among children and teenagers in the United States occurs at a magnitude many times that of other industrialized countries. The trends of injury in this age group relative to the adult population are not well studied. This study seeks to measure trends in pediatric firearm injuries in the United States.Data from the National Trauma Data Bank (2010-2016) were used in selecting patients evaluated for firearm injury. Patients were classified as children and teenagers (20 y) or adults (≥20 y). Changes in the proportion of firearm injuries among children and teenagers relative to the overall population (pediatric component) were determined using trend analyses.There were 240,510 firearm injuries with children and teenagers accounting for 45,075 of these injuries (pediatric component of 18.7%). Pediatric firearm injury was mostly among males (87.4%), Blacks (60.7%), and victims of assault (76.0%). The pediatric component of firearm injuries decreased from 21.7% in 2010 to 18.2% in 2016 (P-trend 0.001). Although there was a decrease from 22.7% to 17.6% in the pediatric component of assault (P-trend0.001), there was an increase from 8.7% to 10.1% in the pediatric component of self-inflicted injuries (P-trend = 0.028). Substratification by race/ethnicity showed decrease in the pediatric component of firearm injuries among all groups (P-trend0.001) except Whites (P-trend = 0.847).Despite reductions in the pediatric component of firearm injuries, there remains a significant burden of injury in this group. Continued public health efforts are necessary to ensure safety and reduce firearm injuries among children and teenagers in the United States.

Background Most hospitals in the United States are required to provide emergency care to all patients, regardless of insurance status. However, uninsured patients might be unable to access non-acute services, such as post-discharge inpatient care (PDIC). This could result in prolonged acute hospitalization. We tested the hypothesis that insurance status would be independently associated with both PDIC and length of stay (LOS). Methods An observational study was undertaken using the California State Inpatient Database (2007-2011), which captures 98% of patients admitted to hospital in California. All patients with a diagnosis of orthopedic lower limb trauma were identified using International Classification of Diseases, 9th Revision, Clinical Modification codes 820-828. Multivariable logistic and generalized linear regression models were used to adjust odds of PDIC and LOS for patient and hospital characteristics. Results There were 278,573 patients with orthopedic lower limb injuries, 160,828 (57.7%) of which received PDIC. Uninsured patients had lower odds of PDIC (adjusted odds ratio 0.20, 95% confidence interval 0.17-0.24) and significantly longer hospital LOS (predicted mean difference 1.06 [95% confidence interval 0.78-1.34] d) than those with private insurance. Conclusions Lack of health insurance is associated with reduced access to PDIC and prolonged hospital LOS. This potential barrier to hospital discharge could reduce the number of trauma beds available for acutely injured patients.

Background Designated trauma centers improve outcomes for severely injured patients. However, major trauma workload can disrupt other care pathways and some patient groups may compete ineffectively for resources with higher priority trauma cases. This study tested the hypothesis that treatment at a higher-level trauma center is an independent predictor for worse outcome after appendectomy. Methods An observational study was undertaken using an all-payer longitudinal data set (California State Inpatient Database 2007–2011). All patients with an ICD-90-CM diagnosis of “acute appendicitis” (International Classification of Diseases, Ninth Revision, Clinical Modification code 540) that subsequently underwent appendectomy were included. Patients transferred between hospitals were excluded to minimize selection bias. The outcome measures were days to the operating room, length of stay, unplanned 30-d readmission (to any hospital in California), and in-hospital mortality. Logistic and generalized linear regression models were used to adjust for patient- (age, sex, payer status, race, Charlson comorbidity index, weekend admission, and generalized peritonitis) and hospital-level (teaching status and bed size) factors. Results There were 119,601 patients treated in 278 individual hospitals. Patients in level I trauma centers (L1TCs) reached the operating room later (predicted mean difference 0.25 d [95% confidence interval 0.14–0.36]), stayed in hospital longer (0.83 d [0.36–1.31]), and had higher adjusted odds of generalized peritonitis (odds ratio 1.63 [95% confidence interval 1.13–2.36]) than those in nontrauma centers. There were no differences in mortality or unplanned 30-d readmissions to hospital; or between level II trauma centers and nontrauma centers across any of the measured outcomes. Conclusions Odds of generalized peritonitis are higher and hospital length of stay is longer in L1TCs, although we found no evidence that patients come to serious harm in such institutions. Further work is necessary to determine whether pressure for resources in L1TCs can explain these findings.

Background It is becoming increasingly common to publish information about the quality and performance of healthcare organisations and individual professionals. However, we do not know how this information is used, or the extent to which such reporting leads to quality improvement by changing the behaviour of healthcare consumers, providers, and purchasers. Objectives To estimate the effects of public release of performance data, from any source, on changing the healthcare utilisation behaviour of healthcare consumers, providers (professionals and organisations), and purchasers of care. In addition, we sought to estimate the effects on healthcare provider performance, patient outcomes, and staff morale. Search methods We searched CENTRAL, MEDLINE, Embase, and two trials registers on 26 June 2017. We checked reference lists of all included studies to identify additional studies. Selection criteria We searched for randomised or non‐randomised trials, interrupted time series, and controlled before‐after studies of the effects of publicly releasing data regarding any aspect of the performance of healthcare organisations or professionals. Each study had to report at least one main outcome related to selecting or changing care. Data collection and analysis Two review authors independently screened studies for eligibility and extracted data. For each study, we extracted data about the target groups (healthcare consumers, healthcare providers, and healthcare purchasers), performance data, main outcomes (choice of healthcare provider, and improvement by means of changes in care), and other outcomes (awareness, attitude, knowledge of performance data, and costs). Given the substantial degree of clinical and methodological heterogeneity between the studies, we presented the findings for each policy in a structured format, but did not undertake a meta‐analysis. Main results We included 12 studies that analysed data from more than 7570 providers (e.g. professionals and organisations), and a further 3,333,386 clinical encounters (e.g. patient referrals, prescriptions). We included four cluster‐randomised trials, one cluster‐non‐randomised trial, six interrupted time series studies, and one controlled before‐after study. Eight studies were undertaken in the USA, and one each in Canada, Korea, China, and The Netherlands. Four studies examined the effect of public release of performance data on consumer healthcare choices, and four on improving quality. There was low‐certainty evidence that public release of performance data may make little or no difference to long‐term healthcare utilisation by healthcare consumers (3 studies; 18,294 insurance plan beneficiaries), or providers (4 studies; 3,000,000 births, and 67 healthcare providers), or to provider performance (1 study; 82 providers). However, there was also low‐certainty evidence to suggest that public release of performance data may slightly improve some patient outcomes (5 studies, 315,092 hospitalisations, and 7502 providers). There was low‐certainty evidence from a single study to suggest that public release of performance data may have differential effects on disadvantaged populations. There was no evidence about effects on healthcare utilisation decisions by purchasers, or adverse effects. Authors' conclusions The existing evidence base is inadequate to directly inform policy and practice. Further studies should consider whether public release of performance data can improve patient outcomes, as well as healthcare processes.

Percutaneous endoscopic gastrostomy tubes are a means of providing an alternative enteric route of nutrition. This study sought to identify risk factors for the prolonged need of a percutaneous endoscopic gastronomy tube (≥90 days) in adult trauma patients.The trauma database of a level 1 trauma center was queried retrospectively to identify patients who had percutaneous endoscopic gastronomy tubes placed.A total of 9,772 charts were reviewed with 282 patients (2.9%) undergoing successful percutaneous endoscopic gastronomy tube placement. On review of discharged living patients, 195 had adequate clinical documentation to allow for analysis. The mean age was 57.5 years, admission serum albumin was 3.7 g/dL, and Charlson Comorbidity Index score was 1.1. The first recorded mean Glasgow Coma Scale was 10.7, and their Injury Severity Score was 23.2. The mean duration of total hospital stay was 23.8 days, intensive care unit stay was 16.5 days, and in-hospital ventilator days was 11.5. Of the 272 patients, 77 (41.4%) required percutaneous endoscopic gastronomy tubes for90 days. Statistically significant characteristics on univariate analysis included increasing age, a greater Charlson Comorbidity Index score, and a greater number of in-hospital ventilator days. On logistic regression, a Charlson Comorbidity Index score1 (odds ratio 1.27, 95% confidence interval 1.03-1.56, P = .02) and greater in-hospital ventilator days (odds ratio 1.05, 95% confidence interval 1.02-1.09, P.01) were predictive of the need for prolonged percutaneous endoscopic gastronomy tube placement.A Charlson Comorbidity Index score1 and prolonged in-hospital ventilator days were risk factors for the necessity of a percutaneous endoscopic gastronomy tube for ≥90 days after placement. This observation may assist patients/surrogates in decision-making when needing alternative routes for nutrition.

Background It is known that emergency surgery in the elderly is associated with high short-term mortality, but longer-term outcomes are not well described. We hypothesized that 30-day mortality may underestimate the true operative mortality experienced in this cohort. The purposes of this study were to characterize postoperative mortality rates extending to 1 year and to identify preoperative predictors of 1 year mortality after emergency abdominal surgery. Methods We retrospectively reviewed the records of all patients older than 70 years who underwent emergency abdominal surgery at a major teaching hospital between 2006 and 2011. Demographics, preoperative physiology, prehospital status, body mass index, laboratory values, Charlson scores, comorbid conditions, American Society of Anesthesiologists classification, and operative details were recorded. The primary end point was 1-year mortality. Complementary log-log binary regression was used to determine independent predictors of death. Model discrimination was evaluated using the c statistic. Results A total of 390 patients met our inclusion criteria. The mean age was 79 years, and 56% were women. Postoperative mortality was 16.2% at 30 days and 32.5% at 1 year, reflecting a doubling of mortality over 11 months. Independent preoperative predictors of 1-year mortality were Charlson score of 4 or higher (hazard ratio [HR], 1.79; 95% confidence interval [CI], 1.38-2.34), American Society of Anesthesiologists class of 4 or higher (HR, 1.66; 95% CI, 1.22-2.21), albumin less than 3.5 (HR, 1.71; 95% CI, 1.31-2.28), and body mass index lower than 18.5 (HR, 3.36; 95% CI, 1.48-6.86). The c statistic was 0.81. Conclusion The 1-year mortality after emergency surgery in the elderly is significantly higher than that at 30 days. We identified a constellation of preoperative clinical markers that were highly predictive of this poor late outcome. The presence of these findings in the emergency setting should prompt preoperative discussion about treatment goals and encourage surgeons to set realistic expectations about outcomes with the patient and family. Future studies will develop a clinical scoring tool that can be applied at the bedside to provide more effective counseling for this high-risk population. Level of evidence Epidemiologic/prognostic study, level III; therapeutic study, level IV.

Background: As the USA seeks to expand the conduct and dissemination of comparative effectiveness research (CER), views of key stakeholders will help guide the way. Methods: We surveyed 60 medical and pharmacy directors from 46 state Medicaid programs. Results: Over 90% felt that CER would lead to better clinical decision-making and overall value within 5 years and were willing to consider cost–effectiveness in setting medical policy. However, perceived poor quality, inconclusive research, restrictive legislative mandates, lack of budget impact and coverage recommendations, and lack of an independent body to interpret study results were major barriers cited to using CER evidence. Conclusion: Given the significant resources being invested in CER, it is critical that these barriers are overcome to maximize its usefulness for stakeholders.

Background: Preventing tobacco use is a key aspect of health promotion during adolescence. We assessed prevalence and impact of school-based tobacco prevention programs in 43 countries. Methods : We performed a secondary analysis of national data of students aged 13–15 years (Global Youth Tobacco Surveys) from 43 countries during 2005–2011. National surveys of the corresponding school personnel (Global School Personnel Surveys) were performed in each country during the same year as the student surveys. Data on status of enforcement of national smoke-free school policies were obtained from the 2008 and 2009 WHO MPOWER reports. Logistic regression was used to measure ecologic-level associations between school-based tobacco prevention programs and tobacco-related knowledge and behaviour among students ( P < 0.05). Results : The proportion of students who were taught in class about the dangers of tobacco use during the school year ranged from 31.4% (Georgia) to 83.4% (Papua New Guinea). For every 10% increase (country level) in the proportion of teachers who reported having a tobacco prevention curriculum in their school, the odds of students reporting exposure to education in class about the dangers of tobacco increased by 6.0% (AOR = 1.06; 95% CI: 1.04–1.08). However, didactic education in class about the dangers of tobacco use was not independently associated with student current cigarette smoking behavior. Conversely, the likelihood of being a current smoker was significantly lower among students in countries with moderate/strongly enforced national smoke-free school policies compared with those in countries with poorly enforced/no national smoke-free school policies (AOR = 0.59; 95% CI: 0.45–0.76). Conclusions: Comprehensive tobacco prevention programs that include well-enforced smoke-free school policies may help reduce youth smoking.

The aims of this study were to assess for changes in uninsured rates among trauma patients at age 64 versus 65 years and whether there are associated changes in post-discharge rehabilitation; determine whether changes are driven by rehabilitation provided at home, skilled nursing facilities (SNFs), or acute inpatient facilities; and determine whether changes vary among stratified subgroups of trauma-related "best-practice" factors.Rehabilitation is an important component of high-quality trauma systems with access heavily influenced by insurance status. In the wake of policy changes affecting insurance coverage, it remains unknown the extent to which insurance changes associate with variations in rehabilitation access/use among otherwise similar patients.Regression discontinuity models were used to assess for changes in insurance status and rehabilitation at age 64 versus 65 years among adults ages 54 to 75 years (±10 years age-related Medicare eligibility). Data were extracted from the 2007-2012 National Trauma Data Bank.A total of 305,198 patients were included; 40.1% were discharged to rehabilitation. Medicare eligibility was associated with an abrupt 6.4 (95% confidence interval: 5.8-7.0) percentage-point decline in uninsured and a 9.6 (95% confidence interval: 6.5-12.6) percentage-point increase in rehabilitation at age 64 versus 65 years, enabling an additional 1-in-10 patients to access rehabilitation. Differences were driven by SNF use and were greatest among patients with less-severe clinical presentations. Restriction based on Medicare-payment eligibility to patients with length of stay ≥3days (SNF requirement) and ≥1 "presumptive diagnosis codes" (inpatient facilities' 60% rule) demonstrated abrupt gains in both SNF and inpatient care.The results reveal the magnitude of changes in access to rehabilitation associated with changes in insurance coverage at age 65 years. Use of quasiexperimental models enabled meaningful consideration of health-policy change.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the benefits and harms of different opioid pharmacological agents given in the pre‐hospital setting for pain caused by traumatic injury.